What do I need to accomplish today? Survey the work area 

1-2-3-4-

Company:_______________________________Job/Task covered:_________________________ Give Job InstructionJob #:__________ Date:____________ 

LACK OF KNOWLEDGmost frequent causes omust show the employand must make sure tknowledge and skill to p

Equipment Needed for Task(s).

Tools Needed for Task(s). 

Supervisor:______________________________

PRIOR TO S

Establish Work MethoA supervisor must estawell understood and coto ensure efficient and sHazards need to be recso proper controls can bacceptable level of risk. responsibility to routine1. Identify unsafe c2. Follow up on any 3. Identify the appro

PRE-TASK PLAN

shall be reviewed with each crew.

Prior to each days work a Pre-Task Plan 

ACTION ITEMS

Employees covered by this Pre-Task Plan

Initial here.

___________________________ _______

Assign people to task

___________________________ _______ Did I complete my tasks?___________________________ _______ Yes No___________________________ _______

1-

___________________________ _______

2-

___________________________ _______ 3-___________________________ _______

4-

___________________________ _______

Supervising people at 

___________________________ __________________________________ _______ Name:

___________________________ _______ Reason:___________________________ _______ Name:___________________________ _______ Reason:

 (complete reprimand form for written warnings)

Whenever a supervisor safety as well as good jthat they be sure the emjob and thoroughly undeRemember even the moneeds some direction.

Warnings Issued

Review the Pre-Task Pla

Complete and return this form to your superintendent

When people deviate frpractices, accidents and people at work is necessupervisor must watch fand correct them as soo

Print Name
 Falling Objects

 High Noise  Harness and Lanyards  Inspected D Walking / Working Surfaces  Retractable Lanyards  Tied/brace Slips / Trips / Falls  Guard Rails  Fully Plank Hot Surfaces/welding/cutting  Hole Covers  Guardrails  Heavy Lifting  Floor / Wall Openings  Access Lad Sharp Objects  Falling Material Eye Hazards  Horizontal Lifelines Hand Hazards  Vertical Lifelines  Permit Req Foot Hazards  Atmospher

 Falls From over 6 foot  Attendant l

 Leading Edge Work  Power tools inspected  Retrieval E Floor / Wall Openings  Check Cords Climbing Ladders  Ground Pins in place Pinch Points  GFCI Used  Fresh Wate Hand / Power tools  Damaged Tools / Cords Removed  First Aid Ki Excavations / Trenches  LockOut / Tagout  Rest Room Scaffolding  MSDS Ava

 Traffic  Trash and 

 Machinery / Equipment  Competent Person  Material St Electrical  Blue Stakes called

Excavations

Potential Hazards Hazard Elimination (cont'd) Hazard Elim

Confin

Electrical

Health and 

Fall Protection Sc

 Rigging  Shoring/Benching/Sloping Other Crafts  Access Ladders Any near miss today? 

 Struck By  Barricades

 Water Controlled

Reported to Safety? Near miss form comp

 Inspected / greased daily Action taken to preven

 Hard Hat  Be Aware of Pinch Points Safety Glasses  Stay out from under loads Reflective Orange  Inspect Rigging Face Shield  Spotter Gloves Accidents/injuries rep Respirators Foot Protection  Ladders tied and secure Name: Ear Plugs  Ladders extend 3' above landing

 4:1 Ratio Reported to Safety? 

 Step ladders opened and locked Incident report comple

 Fire Extinguishers charged  Keep 3 Points of Contact Water Hose on hand  Belt Buckle Rule Supervisor sign and dat Flammables/Combustables isolated Hot Work Permit  Communication with Others ___________________

Signature 

Near Miss/In

Hazard Elimination

Fire Protection

P.P.E.

Equipment

Ladders